Morning Report

22 January 2009

Supervisor : dr. Punarbawa, SpOG

Medical Student: 1. Hadian 2.Miftah 3.Ayu
Cases resume : 1. 2. 3. 4. Normal labor Neglegted in 2nd stage of labor Menorhagia + anemia

1 1

1.

Name / Age Address

Time 17.30

: Mrs. sukriawati / 25 years old : Lingsar

Subject Object General status : General condition: weak Conciousness: CM BP: 120/80 mmHg RR: 22 x/mnt PR: 96 x/mnt T: 38 C (rectal) Eyes : an(-), ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : head L4 : head descensus 3/5 UFH: 32 cm EFW : 3100 gram UC : 3x/10 ~40 Fetal Heart Rate : 16-17-16 VT : DC complete, eff 100 %, AM (), head palpable, descensus HII, pontanella minor transverse lie on left side, caput (+), umbilical cord or small part of fetal unpalpable, Pelvic evaluation Spina ischiadica unpalpable Coxigeal mobile Distantia tuberum >90

CTH

: 22 January 2009 : 17.30

Planning Observation mother and fetal well being. Laboratory examination : DL, HBsAg Resucitation intrauterine Report to supervisor proposed SC agree

Time
Assesment

Patient refered by PKM lingsar (dr Putu Sugiartha) with G1P0A0H0 40 Weeks/S/L/IU head presentation + neglected labor chronologis : 06.30 (22-1-09) Patient confess abdominal discomfort . Examination in PKM: General status: well BP: 120/80 mmHg RR: 22 x/mnt PR: 90 x/mnt t: 36,5C UFH: 32 cm FHB: 154 x/mnt 02.30 (22-1-09) VT: DC 2 cm eff 20 % AM(+), head palpable, descensus HI, umbilical cord or small part of fetal unpalpable, 06.30 (22-1-09) VT: DC 3 cm, eff 30 % AM(+), head palpable, descensus HII, umbilical cord or small part of fetal unpalpable, 11.30 (22-1-09) VT: DC 6 cm, eff 60 %, AM(+), head palpable, descensus HII, umbilical cord or small part of fetal unpalpable, 15.30 (22-1-09) VT: DC complete, eff 100 % AM(-), head palpable, descensus HIII, umbilical cord or small part of fetal unpalpable, Tx: IVFD RL injection ampicilin Obstetric history: 1.This

G1P0A0H0 A/S/L/IU head presentation neglected in 2nd stage of labor + fetal disstres.

LMP : forgot

Time
18.00

Subject
abdominal discomfort(+)

Object
General condition: weak BP: 120/80 mmHg FHB: 16-16-17

Assesment
G1P0A0H0 A/S/L/IU head presentation neglected in 2nd stage of labor + fetal disstres.

Planning
Skin test cefotaxim (-) Injection cefotaxim 2 gram Applied douer catheter

19.00

Send patient to operation room

19.30

Baby was born, male, AS: 7-9, W: 3400 g, caput (+), AF clear, placenta complete.

4th stage of labor

Observation 4th stage of labor

21.30

General status:well BP:110/70 mmHg PR: 84x/mnt UC: well Bleeding (-)

Name / Age Address

Time 19.45

: Mrs. Isal / 45 years old : Lingsar

Subject Object General status : General condition: weak Conciousness: CM BP: 110/70 mmHg RR: 20 x/mnt PR: 80 x/mnt T: 36,6 C Eyes : an(+), ikt (-) Cor -Pulmo : in normal range Abdomen: mass (-), UFH unpalpable, pain (-) Inspection: bleeding (+) Inspeculo: bleeding (+) VT: DC (-) CUAF S/C :normal, AFCD: normal

CTH

: 22 January 2009 : 20.00

Planning Observation vital sign IVFD RL Report to supervisor: advice Pro transfution 3 kolf PRC Remove patient to melati room

Time
Assesment Menorhagia + anemia

Patient came to emergency care unit with mensturasi day 7. mens contineu bleeding.involved 3 sarung per days.abdominal pain (-) Menstural history : reguler, once a month Family planning history: injection per 3 month for last 2 years Obstetric history: P7A0H6

Lab: Hb: 5,6 g% WBC: 7600/mm3 PLT: 384.000/mm3 HCT:15,7 %

Time
22.50

Subject Patient confess abdominal discomfort more often

Object

Assesment
G2P1A0H1 38-39 weeks/S/L, breech presentation, 1st stage of labor active phase

Planning
Observation mother and fetal well being. Laboratory examination : DL, HBsAg Report to supervisor: advice : o Labor pervaginam.

23.10

Baby was born, female, AS: 7-9, W: 3000 g, L: 48 cm, kongenital anomali (-)

Name Age Address

Waktu

: Mrs. Raehan : 29 years : Lombok Tengah Subject

admited

: 23-01-09 : 00.00 pm

Object

Assesment G2P0A1 H0 A/T/H with PROM

Planning Observation mother and fetal well being. Test ampi Injection ampicillin 1 g/IV Laboratory examination : DL, HBsAg Report to supervisor: advice : purposed : induction with oxy drip. Advice: agreed

12.50

Patient refered from PKM Teratak with G2P0A1 A/S/L +PROM chronologis : Pasient confess watery vaginal discharge since 01.00 pm (21-1-09) + Abdominal discomfort (+), fetal movement (+). Then she went to PKM teratak at 09.30 pm. From PKM teratak, patient refered to RSU Praya at 10.00 pm . Because at RSU Praya, patient refered to RSU mataram Therapy from PKM teratak -Infus RL -Amoxilin 3x1 gr/IV

General status : General condition: well, Conciousness: CM BP: 120/80 mmHg RR: 30 x/mnt Pulse :90 x/mnt T: 37,1 C Eyes : an(-) ikt (-) Cor -Pulmo : in normal range Obstetric status : L1 : breech L2 : left back L3 : head L4 : was pelvic inlet 4/5 UFH 29 cm EFW : 2790 g UC : (+) 2x/1020-30 Fetal Heart Beat : 10-11-10 Inspection : active bleeding (+) VT : P 1 cm, eff 25% AM (-), clear, head palpable, denom unclear, descend H1, small organ and umbilical cord unpalpable. Pelvic evaluation : Spina ischiadica: unpalpable Coxigis: mobile Distansia tuberum: >90

LMP: forgot ANC : routine in posyandu + puskesmas, last ANC at 21-01-09 Obstetric history: 1. Abortus 2. This

Time

Subject

Object

Assesment

Planning

History of family injection for 3 month

planing

Bishop score: 5 Dilatation cervix: 0 Length of cervix: 1 Station: 1 Consistensi: 2 Position of cervix: 5
FHB : 10-11-10 UC (+) : 2x/1010-20

G2P0A1 H0 A/T/H with PROM

01.30 am

Mother felt abdominal pain

G2P0A1 H0 A/T/H with PROM

Start drip oxytocin 8 drop/mnt Observation mother fetal wellbeing drip oxytocin 12 drop/mnt Observation mother fetal wellbeing drip oxytocin 16 drop/mnt Observation mother fetal wellbeing drip oxytocin 20 drop/mnt Observation mother fetal wellbeing drip oxytocin 20 drop/mnt Observation mother fetal wellbeing

02.00 am

Mother felt abdominal pain

FHB : 11-10-10 UC (+) : 2x/1030

G2P0A1 H0 A/T/H with PROM

02.30 am

Mother felt abdominal pain

FHB : 11-11-10 UC (+) : 2x/1040

G2P0A1 H0 A/T/H with PROM

03.00 am

Mother felt abdominal pain

FHB : 12-11-11 UC (+) : 3x/1045

G2P0A1 H0 A/T/H with PROM

03.30 am

Mother felt abdominal pain

FHB : 12-11-11 UC (+) : 3x/1045

G2P0A1 H0 A/T/H with PROM

Time

Subject

Object

Assesment

Planning

04.00 am

Mother felt abdominal pain

FHB : 10-11-11 UC (+) : 3-4x/1045

G2P0A1 H0 A/T/H with PROM

drip oxytocin 20 drop/mnt Observation mother fetal wellbeing

drip oxytocin 20 drop/mnt Observation mother fetal wellbeing drip oxytocin 20 drop/mnt Observation mother fetal wellbeing

04.30 am

Mother felt abdominal pain

FHB : 11-11-10 UC (+) : 4x/1050

G2P0A1 H0 A/T/H with PROM

05.00 am

Mother felt abdominal pain

FHB : 11-11-11 UC (+) : 4x/1050 VT: P 7 cm. eff 75%, AM (-) clear, head palpable, denom fontanella minor , descend HII

G2P0A1 H0 A/T/H Active phase II stage of labor + history of watery vaginal discharge

03.00 am

FHB : 12-11-11 UC (+) : 3x/1045

G2P0A1 H0 A/T/H with PROM

Start drip oxytocin 8 drop/mnt Observation mother fetal wellbeing drip oxytocin 12 drop/mnt Observation mother fetal wellbeing

03.30 am

FHB : 12-11-11 UC (+) : 3x/1045

G2P0A1 H0 A/T/H with PROM

Time

Subject

Object

Assesment

Planning

Time

Subject

Object

Assesment

Planning

Time

Subject

Object

Assesment

Planning